Pressure Ulcer Dilemma in the Emergency Department Environment

by James G. Spahn, MD, FACS

The Emergency Department (ED) environment has changed considerably over the past 30 years, increasing awareness of pressure ulcers that develop in the ED. Patients treated in the ED range from those with life threatening events to non-emergent outpatient problems. This variance in the patient’s level of acuity creates a triage sensitive environment.

The need to triage patients is beneficial for addressing the acuity of the problem, but sometimes it defers care for the less severe conditions. This selection process creates a problem for the patient at risk for pressure ulcer development who may not require immediate care. This disconnect could delay recognition, assessment, and communication about the potential for pressure ulcer development.

Risk factors relating to pressure ulcer prevention and treatment may not be considered serious enough to be addressed in the ED setting. This creates a potentially dangerous situation as pressure ulcers can develop in as little as two hours without proper precautions and/or treatment. (CMS Manual System – Tag F314). To illustrate the magnitude of the problem, 40% of hospital admissions through the ED increased to 54% between 1997 and 2003. (Kelley, William, 1997) (Owens, Elixhauser, 2006). Today, the average stay in the ED is three hours, but can be 24 hours or longer. “Boarding” is a practice used when overcrowded conditions require a patient to remain in the ED until a hospital bed is available (Centers for Disease Control and Prevention, 2003). These patients are left on gurneys for up to 48 hours, compromising their skin and overall care.

The most important component of pressure ulcer prevention and treatment is simply awareness of the problem by the ED staff. It is evident by comparing the admitting diagnosis with the co-morbidity diagnosis associated with pressure ulcers, that the ED should be the entry medical care setting for patients at risk for pressure ulcers (Owens, Elishauser, 2006) (Russo, 2006). Every patient, regardless of how life threatening or routine their problem, must be evaluated for pressure ulcer risk factors. And staff education is the key to beginning this evaluation in the ED. The risk analysis should address each risk factor separately. Risk factors include: limited mobility/ambulation, malnutrition/dehydration, moisture/incontinence, chronic general medical conditions and medication that predispose patients to pressure ulcer development or delayed healing and existing/closed pressure ulcer. The skin and soft tissue in and around bony prominences, especially the sacrum, heel, trochanter, elbow, ischial tuberosity and cranium should be visually inspected and palpated. Inspection will help determine if the skin and the soft tissue trapped between the bony skeleton and surface has been damaged (NPUAP, 2005). Many ED personnel believe that if skin ulceration is not evident immediately following an ED stay, then soft tissue injury has not occurred. This thought process is dangerous to the patient and must be corrected.
Unfortunately, mobility and ambulation is not often practiced in the ED. Life threatening situations will necessitate immobility and no ambulation. Patients who can ambulate are instructed to remain on carts or in chairs to prevent disruptions in the ED. Nutritional restrictions, secondary to medical necessity, complicate the malnutrition risk factor for pressure ulcer prevention and treatment. Dehydration is usually addressed timely by either oral intake or IV therapy. Excessive skin moisture and/or fecal and urinary incontinence may be missed in patients with limited communication, but without life-threatening conditions. An existing wound or a closed pressure ulcer can easily be overlooked during the initial triage history and physical. Records relating to medical condition and medication in use are often unavailable to ED personnel for a significant period of time. When medical records, medical conditions and medications are available, a patient still may not be identified as having a risk for pressure ulcer development or a healing delay of an existing pressure ulcer.

Compounding the problem is the fact that the support surfaces in the ED environment are ineffective in preventing and treating pressure ulcers (Duncan, Spahn,2000) (Hobbs, Spahn 1988). Surfaces range from back boards, to firm, foam covered pads, to firm chairs. There are no commonly used surfaces in the ED that will deliver equalized volumetric support to the soft tissue at risk. Horizontal positioning of the patient, puts the heels at great risk to develop pressure ulcers. Risk heightens when no attention is given to the foot-ankle-heel complex or when loading of the heel, malleolus or side of foot occurs.

In my opinion, it is imperative that health care professionals understand how a deep tissue injury can begin to develop within two hours, but may not be recognized for two to seven days (CMS,Tag 314) (NPUAP, 2005).

Understanding pressure ulcer pathophysiology means understanding that tissue at risk is three dimensional and must be volumetrically supported to avoid soft tissue distortion. Distortion increases the likelihood of an ischemic necrosis to developing in the soft tissue (Spahn, Sprinkle 1999). Generally it is not recognized that an ischemic event can occur with no skin involvement. In other words, the skin looks intact but it is masking subcutaneous, or deep tissue injury. And, to make matters worse, the deeper the ischemic injury, the longer it takes to be diagnosed. NPUAP defines a deep tissue injury as a pressure-related injury to subcutaneous tissues under intact skin. Initially these lesions have the appearance of a deep bruise. These lesions may herald subsequent development of Stage III-IV pressure ulcer even with optimal treatment ( NPUAP, 2005).” The pathophysiology of pressure ulcer development, along with the recognition of deep tissue injury, must be understood before hospital acquired pressure ulcers can be prevented. This will not only impact the overall pressure ulcer problem approach in the general medical/surgical arena, but will also significantly impact patient care in the ED environment.

Patients who are at risk of acquiring a pressure ulcer or have an existing ulcer must be placed on a support surfaces that delivers equalized redistribution of pressure and shear. Those at risk with limited ambulation/mobility also require an appropriate lower extremity device. This device should totally unload the heel while maintaining the calf’s normal configuration. Other specific risk factors should be addressed following appropriate medical standards of care.

The recommended clinical treatment plan specific to each risk factor must be communicated to the patient or legal advocate. The clinical treatment plan along with the care chosen by the patient determines the individualized care plan. Each individualized care plan must have goals established for a specific time frame, be re-evaluated on a scheduled basis and changed if no improvement occurs or if risk factors change. It is essential that this process be documented in real time.

This comprehensive approach, along with a simple visual alert prompt (such as a bracelet) placed immediately on the at-risk patient will promote a seamless continuum of care (CBC, 2006). This approach provides good medical care and fulfils regulatory and legal requirements.

In conclusion, awareness of the pressure ulcer problem must occur through education, promotion and visual prompts. Individualized care plans need to be implemented and documented by the professional caregiver, and then communicated to the patient and/or legal advocate in a timely fashion. Only by accomplishing these tasks can we properly address the pressure ulcer prevention and treatment quandary. If we follow through with this plan, the patient, clinician and facility or agency will all benefit.

References

Centers for Disease Control and Prevention; Advance Data No. 335, June 4, 2003.

CBC, Concepts Brokers Corporation. (2006). Alert Wear™ Available: http://www.conceptbrokerscorp.com.

Draft -Candidate 2007 National Patient Safety Goals, Requirements and Implementation Expectations -Hospital and Critical Access Hospital Programs

JCAHO Joint Commission on Accreditation of Healthcare Organizations

Duncan, C., Spahn, J. edited by Lorraine Butts. Effects of a Support Surface on Homeostasis – Keep it Simply Scientific. Poster and paper presented at WOCN, 2000.

Hobbs, L., Spahn J., Support Surface Principles-Based on Scientific Fact, Poster, 1988.

Kelley, William., Textbook of internal Medicine. 1997; Third Edition, p. 280.

Link to CMS Manual System – Tag F314 http://new.cms.hhs.gov/transmittals/Downloads/R5SOM.pdf

National Pressure Ulcer Advisory Council Deep Tissue Injury. White Paper 2005; pp. 1-5.

Owens, E., Elixhauser, A. (2006). Reasons for Being Admitted to the Hospital through the Emergency Department, 2003. Statistical Brief #2. Agency for Healthcare Research and Quality and Healthcare Cost and Utilization Project.

Owens, E., Elixhauser, A. (2006). Hospital Admissions that Began in the Emergency Room, 2003. Statistical Brief #1. Agency for Healthcare Research and Quality and Healthcare Cost and Utilization Project.

Russo, A. (2006). Hospitalizations Related to Pressure Sores, 2003. Statistical Brief #3. Agency for Healthcare Research and Quality and Healthcare Cost and Utilization Project.

Spahn, J., Sprinkle C., Support Surface Principles-Based on Scientific Fact. Japanese Journal of Pressure Ulcers 1999; Vol. 1, pp.243-47.

Thomas, D. Prevention and treatment of pressure ulcers: What works? What doesn’t? Cleveland Clinic Journal of Medicine August 2001; Vol. 68, pp.704-22.

Copyright 2006 EHOB, Inc.

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Effects of a Support Surface on Homeostasis –
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